Boy's death prompts new measures to safeguard patients in Wales

Lesley Griffiths has announced changes after a report into the death of Robbie Powell

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Health Minister Lesley Griffiths has outlined new measures to safeguard patients following the death of a Welsh schoolboy 22 years ago.

The changes, which centre around clinical governance and improving services and patient safety, come after a report into the death of 10-year-old Robbie Powell.

Robbie died at Swansea’s Morriston Hospital in 1990 after a succession of doctors failed to diagnose and treat the life-threatening glandular condition Addison’s Disease.

Since then, Robbie’s family has campaigned relentlessly for a full and open inquiry and alleged that doctors forged medical records in an attempt to cover up their mistakes.

A 14-month investigation was called by First Minister Carwyn Jones in 2010 to look at the lessons the NHS could learn from the circumstances of Robbie’s death.

Following the publication of the report in July, Mr Jones said it uncovered a “catalogue of errors, a catalogue of sometimes bad luck, but above all else a catalogue of neglect, neglect by a system that was meant to be there to help a 10-year-old boy who had a disease that was curable”.

The report made 12 recommendations, relating to communication to ensure continuity of care, management of medical records, communication with patients and their families and dealing with concerns and complaints following the death of a patient.

In statement to plenary on Tuesday, Health Minister Lesley Griffiths apologised to Robbie’s parents and outlined the Welsh Government’s response to these recommendations.

She said: “I know we were all saddened to hear of the catalogue of failures and missed opportunities surrounding Robbie’s tragic death. This pain has been made all the worse for his family by the subsequent events and investigations, none of which have brought satisfactory answers for them. Today our thoughts and sympathies are again with Robbie’s family and friends.

“Sadly, we cannot turn back the clock. However, I am determined to ensure we do all we possibly can to make further improvements in our systems to improve patient safety and care.

“The purpose of this investigation was to identify learning for the NHS. Today, therefore, I want us to look forward and ensure we build on the report’s recommendations. This also provides an opportunity to focus on the needs of children in accessing healthcare, ensuring their voice is heard and they are fully engaged in decisions about their health and healthcare.

Clearly a great deal has changed in the NHS over the past twenty years. However, we can never be complacent. There is and always will be room to improve. Healthcare never stands still.

“Our clinicians and healthcare staff work tirelessly to do their very best for the people of Wales. A service as complex as healthcare can never be perfect. Sadly mistakes occasionally will happen. However, when this happens we must ensure we take every opportunity to learn from those mistakes.

“I sincerely hope the actions I have outlined today provide some comfort to Mr and Mrs Powell and their family. I too want to say sorry for what they have had to endure. Sadly, however, I realise no amount of effort by the Government will ever be able to make good their loss. We can only realistically hope to learn from this tragedy and remain vigilant for our patients in the future.”

Since Robbie’s death all unexpected child deaths are subject to an immediate multidisciplinary procedural response and health boards are now required to reassess their performance with Healthcare Inspectorate Wales providing independent reviews.

Ms Griffiths said further measures to be taken by the Welsh Government following the report include plans to review guidance for copying letters to patients to include specific guidance on children and young people who are capable of giving consent to treatment themselves.

Meanwhile, there will be further regulation on access to medical records of deceased patients, with records being “locked-down” so no changes can be made following their death.

There are also plans to roll-out electronic individual health records the whole population by 2013-14 to allow staff in out-of-hours services to see parts of the GP record in an emergency. Records will also include reports from any other health professional who has provided clinical services to patients.

A clinical communications gateway will also be set up for all practices to give GPs the power to refer patients to hospitals so emergency referrals can be dealt with on the same day. Discharge information and outpatient letters will also be sent electronically to GPs.

Meanwhile, health boards will be required to make sure internal communication systems and safeguards are in place for suitable handover arrangements when doctors are off-duty.

By 2013, all health boards must take a review of their governance arrangements for assuring the quality of primary care, including their communication systems.

Healthcare Inspectorate for Wales will then carry out a number of reviews throughout 2013-14 to test the processes.